Archive: Around Town

Tompkins County is one of 23 new sites announced by the Centers for Medicare & Medicaid (CMS) partnering to improve the quality of care available to high-risk Medicare beneficiaries.  The Tompkins County Office for the Aging is working together with Cayuga Medical Center, Visiting Nurse Service and Hospicare and Palliative Care Services on the Community-Based Care Transitions Program.  This new initiative will assist high risk Medicare patients as they transition from the hospital to home.

Studies have found that patients with chronic diseases such as Congestive Heart Failure (CHF) and Chronic Obstructive Pulmonary Disease (COPD) have difficulty managing their care and medications once they are discharged from the hospital. Through Tompkins County’s Community-Based Care Transitions Program, trained staff will work with eligible patients after discharge, using strategies proven to empower high-risk patients to better mange their own care and to reduce unnecessary re-hospitalizations.

To help the Tompkins Office for Aging and its partners take advantage of this new opportunity, the Community Health Foundation of Western and Central New York supported the development of the application to the Community-based Care Transitions Program through grant funding and expertise provided by its advisors.  The Foundation has worked for more than six years to support organizations in their mission to improve care transitions for elders, focusing on building more effective partnerships between health care providers and caregivers to improve continuity, reduce errors and delays and increase the amount of control patients and their caregivers have over health decisions.

Additional key partners who have worked to bring this important effort to Tompkins County include the Health Planning Council of Tompkins County, Tompkins County Department of Social Services, Cayuga Ridge Extended Care Center, Beechtree Care Center, Tompkins County Department of Emergency Response and IPRO.

The Community-Based Care Transitions Program was created by the Affordable Care Act and launched in April 2011 as part of the Partnership for Patients initiative. Administered through the CMS Innovation Center, CCTP will provide $500 million in funding to community-based organizations that partner with eligible hospitals for care transition services that include timely, culturally and linguistically competent post-discharge education, medication review and management, and patient-centered self-management support within 24 hours of discharge.

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